Provider Demographics
NPI:1518961036
Name:MUKKADA, THOMAS JOB (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOB
Last Name:MUKKADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 E ALTA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-1413
Mailing Address - Country:US
Mailing Address - Phone:641-682-4115
Mailing Address - Fax:641-682-0005
Practice Address - Street 1:312 E ALTA VISTA AVE
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-1413
Practice Address - Country:US
Practice Address - Phone:641-682-4115
Practice Address - Fax:641-682-0005
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28127207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E92822Medicare UPIN
03934Medicare ID - Type Unspecified